VIVA Health Custom Drug List

April 2016 VIVA Health Custom Drug List The VIVA Health Custom Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by CVS/caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. Please visit www.vivahealth.com for specific information regarding your prescription benefit coverage and copay 1 information. CVS/caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. In most instances, a brand-name drug for which a generic product becomes available will be designated as a nonpreferred option upon release of the generic product to the market. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS/caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to www.vivahealth.com to check coverage and copay information for a specific medicine. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL COX-2 celecoxib GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel ABSTRAL BUTRANS FENTORA NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN SUBSYS VISCOSUPPLEMENTS GEL-ONE 2 HYALGAN 2 SUPARTZ FX 2 ANTI-INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole itraconazole terbinafine tablet 3 ANTIRETROVIRAL ANTIRETROVIRAL ATRIPLA COMPLERA EPZICOM EVOTAZ PREZCOBIX STRIBILD TRIUMEQ TRUVADA FUSION FUZEON 2 INTEGRASE ISENTRESS TIVICAY NON-NUCLEOSIDE REVERSE TRANSCRIPTASE nevirapine nevirapine ext-rel EDURANT INTELENCE SUSTIVA NUCLEOSIDE REVERSE TRANSCRIPTASE abacavir lamivudine EMTRIVA NUCLEOTIDE REVERSE TRANSCRIPTASE VIREAD PROTEASE KALETRA NORVIR PREZISTA REYATAZ

ANTIVIRALS CYTOMEGALOVIRUS valganciclovir HEPATITIS C ribavirin 2 HARVONI 2 REBETOL SOLUTION 2 SOVALDI 2 HERPES acyclovir valacyclovir INFLUENZA RELENZA TAMIFLU MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim ALBENZA SIVEXTRO XIFAXAN 550 MG ANTINEOPLASTIC ALKYLATING lomustine 3 temozolomide 2 ALKERAN 3 CYCLOPHOSPHAMIDE CAPSULE 3 HEXALEN 3 LEUKERAN 3 MYLERAN 3 ANTIMETABOLITES capecitabine 2 mercaptopurine 3 TABLOID 3 HORMONAL ANTINEOPLASTIC ANTIESTROGENS tamoxifen 3 LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate 2 LUPRON DEPOT 2 TRELSTAR 2 ZOLADEX 2 KINASE AFINITOR 2 BOSULIF 2 GLEEVEC 2 NEXAVAR 2 SPRYCEL 2 SUTENT 2 TARCEVA 2 TYKERB 2 VOTRIENT 2 MISCELLANEOUS bexarotene capsule 2 etoposide 3 hydroxyurea 3 tretinoin capsule 3 LYSODREN 3 MATULANE 3 ZOLINZA 2 CARDIOVASCULAR ACE fosinopril lisinopril quinapril ramipril ACE INHIBITOR / CALCIUM CHANNEL BLOCKER amlodipine-benazepril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ADRENOLYTICS, CENTRAL clonidine transdermal ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide telmisartan / telmisartanhydrochlorothiazide valsartan / valsartanhydrochlorothiazide BENICAR / BENICAR HCT ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-telmisartan amlodipine-valsartan AZOR ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC amlodipine-valsartanhydrochlorothiazide TRIBENZOR ANTIARRHYTHMICS amiodarone disopyramide flecainide propafenone propafenone ext-rel sotalol TIKOSYN 2 ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION ZETIA FIBRATES fenofibrate fenofibric acid HMG-CoA REDUCTASE / atorvastatin fluvastatin lovastatin pravastatin simvastatin CRESTOR VYTORIN NIACINS / niacin ext-rel OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters PCSK9 REPATHA 2 BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol propranolol ext-rel BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel 4 nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN / DIURETIC TEKTURNA / TEKTURNA HCT DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER TEKAMLO DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER / DIURETIC AMTURNIDE DIURETICS furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide NITRATES nitroglycerin lingual spray NITROLINGUAL NITROSTAT NITRATE / VASODILATOR BIDIL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS 2 OPSUMIT 2 TRACLEER 2 PHOSPHODIESTERASE sildenafil 2 ADCIRCA 2 PROSTAGLANDIN VASODILATORS REMODULIN 2 TYVASO 2 VENTAVIS 2 SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS 2 MISCELLANEOUS RANEXA CENTRAL NERVOUS SYSTEM ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate valproic acid zonisamide VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel rivastigmine EXELON PATCH NAMENDA NAMENDA XR ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline BRINTELLIX FLUOXETINE 60 MG VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIs) duloxetine venlafaxine venlafaxine ext-rel KHEDEZLA PRISTIQ MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone

LATUDA SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel guanfacine ext-rel methylphenidate methylphenidate ext-rel QUILLIVANT XR STRATTERA VYVANSE FIBROMYALGIA LYRICA SAVELLA HYPNOTICS NONBENZODIAZEPINES eszopiclone 5 zolpidem 5 zolpidem ext-rel 5 TRICYCLICS SILENOR 5 MIGRAINE SELECTIVE SEROTONIN AGONISTS naratriptan 5 rizatriptan 5 sumatriptan 5 zolmitriptan 5 RELPAX 5 ZOMIG NASAL SPRAY 5 SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET 5 MULTIPLE SCLEROSIS AUBAGIO 2 BETASERON 2 COPAXONE 2 GILENYA 2 REBIF 2 TECFIDERA 2 MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY modafinil 3 NUVIGIL 3 POSTHERPETIC NEURALGIA GRALISE 3 PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS EVZIO PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet SUBOXONE FILM VASOMOTOR SYMPTOM BRISDELLE ENDOCRINE AND METABOLIC ANTIDIABETICS ALPHA-GLUCOSIDASE acarbose AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC TRULICITY VICTOZA INSULINS HUMULIN R U-500 LANTUS LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TOUJEO TRESIBA INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) FARXIGA JARDIANCE SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE XIGDUO XR SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD INSULIN SYRINGES AND NEEDLES 6 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM ONETOUCH ULTRA STRIPS ONETOUCH VERIO STRIPS CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate risedronate ATELVIA CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO 2 CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC ethinyl estradiol-norgestimate ORTHO TRI-CYCLEN LO FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS, ORAL estradiol-norethindrone PREMPHASE PREMPRO ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE GLUCOCORTICOIDS methylprednisolone prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES HUMATROPE 2 NORDITROPIN 2 PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO PROGESTINS ORAL medroxyprogesterone progesterone, micronized MEGACE ES SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron 3 prochlorperazine promethazine trimethobenzamide DICLEGIS 6 SANCUSO CHOLELITHOLYTICS ursodiol H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL balsalazide budesonide capsule sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA UCERIS RECTAL hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME LINZESS LOTRONEX LAXATIVES lactulose peg 3350-electrolytes MOVIPREP SUCLEAR SUPREP OPIOID-INDUCED CONSTIPATION MOVANTIK PANCREATIC ENZYMES CREON ULTRESA VIOKACE ZENPEP PROTON PUMP lansoprazole pantoprazole

SALIVA STIMULANTS cevimeline STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin finasteride tamsulosin terazosin AVODART RAPAFLO URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel GELNIQUE MYRBETRIQ HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS PRADAXA XARELTO HEMATOPOIETIC GROWTH FACTORS ARANESP 2 PROCRIT 2 PLATELET AGGREGATION clopidogrel dipyridamole ext-rel-aspirin BRILINTA EFFIENT IMMUNOLOGIC ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK BIOLOGIC DISEASE- MODIFYING ENBREL 2 HUMIRA 2 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO 2 IMMUNOMODULATORS INTERFERONS INTRON A 2 PEGASYS 2 SYLATRON 2 IMMUNOSUPPRESSANTS ANTIMETABOLITES mycophenolate mofetil mycophenolate sodium AZASAN MYFORTIC CALCINEURIN cyclosporine cyclosporine, modified tacrolimus SANDIMMUNE RAPAMYCIN DERIVATIVES sirolimus tablet RAPAMUNE NUTRITIONAL PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT AUVI-Q EPIPEN EPIPEN JR ANTICHOLINERGICS ANTICHOLINERGIC / BETA AGONIST ipratropium-albuterol inhalation solution ANORO ELLIPTA COMBIVENT RESPIMAT BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution PROAIR HFA PROVENTIL HFA VENTOLIN HFA LONG ACTING ARCAPTA PERFOROMIST SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine olopatadine NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX PHOSPHODIESTERASE-4 DALIRESP STEROID / BETA AGONIST ADVAIR DULERA STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR XANTHINES THEO-24 TOPICAL DERMATOLOGY ACNE adapalene 3 benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin 3 ACANYA 3 ATRALIN 3 BENZACLIN 3 DIFFERIN 3 EPIDUO 3 RETIN-A MICRO 3 TAZORAC ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO ZYCLARA ANTIBIOTICS mupirocin BACTROBAN NASAL ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN ANTIPSORIATICS acitretin calcipotriene methoxsalen SORILUX CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency hydrocortisone butyrate mometasone triamcinolone CLODERM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo IMMUNOMODULATORS tacrolimus ELIDEL LOCAL ANALGESICS lidocaine patch ROSACEA metronidazole sulfacetamide-sulfur FINACEA ORACEA SOOLANTRA MISCELLANEOUS SKIN AND MUCOUS MEMBRANE DENAVIR MOUTH / THROAT / DENTAL PROTECTANTS EPISIL MUGARD 2 OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium PATADAY PATANOL PAZEO ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- tobramycin- TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac PROLENSA Steroidal ALREX DUREZOL LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA IMMUNOMODULATORS RESTASIS PROSTAGLANDINS latanoprost travoprost TRAVATAN Z ZIOPTAN SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVES ofloxacin otic ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX

QUICK REFERENCE DRUG LIST A abacavir ABSTRAL ACANYA 3 acarbose acitretin acyclovir adapalene 3 ADCIRCA 2 ADEMPAS 2 ADVAIR AFINITOR 2 ALBENZA albuterol inhalation solution alendronate alfuzosin ext-rel ALKERAN 3 allopurinol ALPHAGAN P ALREX amantadine amiodarone amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel AMTURNIDE ANORO ELLIPTA APRISO ARANESP 2 ARCAPTA aripiprazole ASMANEX ATELVIA atenolol atorvastatin ATRALIN 3 ATRIPLA AUBAGIO 2 AUVI-Q AVODART AZASAN azelastine AZILECT azithromycin AZOPT AZOR B BACTROBAN NASAL balsalazide BD INSULIN SYRINGES AND NEEDLES 6 BENICAR BENICAR HCT BENZACLIN 3 benzoyl peroxide BESIVANCE BETASERON 2 BETIMOL BETOPTIC S bexarotene capsule 2 BEYAZ BIDIL BOSULIF 2 BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide capecitabine 2 carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin cevimeline cholestyramine ciclopirox CIPRODEX ciprofloxacin ciprofloxacin ext-rel citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol cream, foam, gel, lotion, ointment, shampoo CLODERM clonidine transdermal clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIVENT RESPIMAT COMPLERA COPAXONE 2 COREG CR CORTIFOAM COSOPT PF CREON CRESTOR cromolyn sodium cyclobenzaprine CYCLOPHOSPHAMIDE CAPSULE 3 cyclosporine cyclosporine, modified D DALIRESP DENAVIR desonide desoximetasone DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM diazepam rectal gel DICLEGIS 6 diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN 3 DIFICID digoxin diltiazem ext-rel 4 dipyridamole ext-rel-aspirin disopyramide divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUREZOL E econazole EDURANT EFFIENT ELIDEL ELIQUIS EMTRIVA ENBREL 2 entacapone EPIDUO 3 EPIPEN EPIPEN JR EPISIL eprosartan EPZICOM erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone 5 ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiol-norgestimate ethosuximide etoposide 3 EVAMIST EVOTAZ EVZIO EXELON PATCH F FARXIGA fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA FINACEA finasteride flecainide FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil cream 5% fluorouracil solution fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin FORTEO 2 fosinopril fosinopril-hydrochlorothiazide furosemide FUZEON 2 G gabapentin galantamine galantamine ext-rel GELNIQUE GEL-ONE 2 gentamicin GILENYA 2 GLEEVEC 2 glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE 3 granisetron GRASTEK guanfacine ext-rel H HARVONI 2 HEXALEN 3 HUMATROPE 2 HUMIRA 2 HUMULIN R U-500 HYALGAN 2 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel hydroxyurea 3 I ibandronate imiquimod INTELENCE INTRON A 2 ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide ISENTRESS itraconazole ivermectin J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JUBLIA K KALETRA ketoconazole ketorolac KHEDEZLA L lactulose lamivudine lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LETAIRIS 2 LEUKERAN 3

leuprolide acetate 2 LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA lidocaine patch LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LOTION lomustine 3 losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LUPRON DEPOT 2 LUZU LYRICA LYSODREN 3 M MATULANE 3 meclizine medroxyprogesterone MEGACE ES meloxicam mercaptopurine 3 mesalamine rectal suspension metformin metformin ext-rel methadone methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine modafinil 3 mometasone montelukast morphine morphine ext-rel morphine suppository MOVANTIK MOVIPREP MOXEZA moxifloxacin MUGARD 2 mupirocin mycophenolate mofetil mycophenolate sodium MYFORTIC MYLERAN 3 MYRBETRIQ N nadolol NAFTIN NAMENDA NAMENDA XR naproxen naratriptan 5 NASONEX NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- NEUPRO nevirapine nevirapine ext-rel NEXAVAR 2 niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin lingual spray NITROLINGUAL NITROSTAT NORDITROPIN 2 NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL 3 nystatin O ofloxacin ofloxacin otic olanzapine olopatadine omega-3 acid ethyl esters ondansetron 3 ONETOUCH ULTRA STRIPS ONETOUCH VERIO STRIPS OPANA ER OPSUMIT 2 ORACEA ORALAIR ORTHO TRI-CYCLEN LO OSPHENA oxcarbazepine oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN P pantoprazole paroxetine paroxetine ext-rel PATADAY PATANOL PAZEO peg 3350-electrolytes PEGASYS 2 penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRADAXA pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA primidone PRISTIQ PROAIR HFA probenecid prochlorperazine PROCRIT 2 PROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propafenone propafenone ext-rel propranolol propranolol ext-rel PROVENTIL HFA PULMICORT FLEXHALER PYLERA Q quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide QVAR R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RAPAMUNE RASUVO 2 REBETOL SOLUTION 2 REBIF 2 RELENZA RELPAX 5 REMODULIN 2 RENVELA repaglinide REPATHA 2 RESTASIS RETIN-A MICRO 3 REYATAZ ribavirin 2 risedronate risperidone rivastigmine rizatriptan 5 ropinirole ropinirole ext-rel S SAFYRAL SANCUSO SANDIMMUNE SAVELLA selegiline SEREVENT SEROQUEL XR sertraline sildenafil 2 SILENOR 5 SIMBRINZA simvastatin sirolimus tablet SIVEXTRO SOOLANTRA SORILUX sotalol SOVALDI 2 spironolactonehydrochlorothiazide SPRYCEL 2 STRATTERA STRIBILD SUBOXONE FILM SUBSYS SUCLEAR sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan 5 SUPARTZ FX 2 SUPRAX SUPREP SUSTIVA SUTENT 2 SYLATRON 2 SYMLINPEN SYNTHROID T TABLOID 3 tacrolimus TAMIFLU tamoxifen 3 tamsulosin TARCEVA 2 TAZORAC TECFIDERA 2 TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartanhydrochlorothiazide temozolomide 2 terazosin terbinafine tablet 3 tetracycline THEO-24 tiagabine TIKOSYN 2 timolol maleate solution TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin- tolterodine tolterodine ext-rel topiramate torsemide TOUJEO TRACLEER 2 TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone TRELSTAR 2 TRESIBA tretinoin 3 tretinoin capsule 3 TREXIMET 5 triamcinolone triamterenehydrochlorothiazide TRIBENZOR trimethobenzamide TRIUMEQ trospium trospium ext-rel TRULICITY TRUVADA TYKERB 2 TYVASO 2 U UCERIS ULORIC ULTRESA ursodiol V VAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VELPHORO venlafaxine venlafaxine ext-rel VENTAVIS 2 VENTOLIN HFA verapamil ext-rel VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VIREAD VOLTAREN GEL VOTRIENT 2 VYTORIN VYVANSE W warfarin WELCHOL

X XARELTO XIFAXAN 550 MG XIGDUO XR Z zafirlukast ZENPEP ZETIA ZIOPTAN ziprasidone ZOLADEX 2 ZOLINZA 2 zolmitriptan 5 zolpidem 5 zolpidem ext-rel 5 ZOMIG NASAL SPRAY 5 zonisamide ZYCLARA ZYLET PREFERRED OPTIONS LIST DRUG NAME(S) ABILIFY ACCU-CHEK STRIPS ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALORA ALTOPREV ALVESCO AMITIZA AMRIX ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID ARTHROTEC ASACOL HD aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR pioglitazone amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE AUVI-Q, EPIPEN, EPIPEN JR ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR estradiol, DIVIGEL, EVAMIST, MINIVELLE ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR LINZESS cyclobenzaprine estradiol-norethindrone, PREMPHASE, PREMPRO fenofibrate, fenofibric acid desoximetasone, fluocinonide NOVOLOG levothyroxine, SYNTHROID celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole or pantoprazole balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS ASCENSIA STRIPS ATACAND, ATACAND HCT ATROVENT HFA AVONEX 2 AUBAGIO 2, BETASERON 2, COPAXONE 2, GILENYA 2, REBIF 2, TECFIDERA 2 AXERT 5 naratriptan 5, rizatriptan 5, sumatriptan nasal spray 5, sumatriptan tablet 5, zolmitriptan 5, RELPAX 5, ZOMIG NASAL SPRAY 5 AZELEX BECONASE AQ adapalene 3, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin 3, ACANYA 3, ATRALIN 3, BENZACLIN 3, DIFFERIN 3, EPIDUO 3, RETIN-A MICRO 3, TAZORAC DRUG NAME(S) BENZAC AC, BENZAC W BENZIQ BREEZE 2 STRIPS BREO ELLIPTA BYDUREON BYETTA CARAC CARDIZEM CARDIZEM CD CARDIZEM LA (and its generics) CARDURA XL CLINDAGEL clobetasol spray CLOBEX SPRAY CONTOUR NEXT STRIPS CONTOUR STRIPS CYMBALTA DELZICOL DETROL LA DIOVAN, DIOVAN HCT adapalene 3, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin 3, ACANYA 3, ATRALIN 3, BENZACLIN 3, DIFFERIN 3, EPIDUO 3, RETIN-A MICRO 3, TAZORAC adapalene 3, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin 3, ACANYA 3, ATRALIN 3, BENZACLIN 3, DIFFERIN 3, EPIDUO 3, RETIN-A MICRO 3, TAZORAC ADVAIR TRULICITY, VICTOZA TRULICITY, VICTOZA fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA diltiazem ext-rel (except generic Cardizem LA) diltiazem ext-rel (except generic Cardizem LA) diltiazem ext-rel (except generic Cardizem LA) alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO erythromycin solution clobetasol foam clobetasol foam duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, DORAL 5 eszopiclone 5, zolpidem 5, zolpidem ext-rel 5, SILENOR 5 DUEXIS DYMISTA celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole or pantoprazole flunisolide, fluticasone, triamcinolone or NASONEX WITH azelastine or olopatadine

DRUG NAME(S) EDARBI, EDARBYCLOR EDLUAR 5 eszopiclone 5, zolpidem 5, zolpidem ext-rel 5, SILENOR 5 ENABLEX ENJUVIA ESTRING oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, estradiol, estropipate, PREMARIN ESTRACE CREAM, PREMARIN CREAM, VAGIFEM EUFLEXXA 2 GEL-ONE 2, HYALGAN 2, SUPARTZ FX 2 EXFORGE EXFORGE HCT amlodipine-telmisartan, amlodipine-valsartan, AZOR amlodipine- TRIBENZOR EXTAVIA 2 AUBAGIO 2, BETASERON 2, COPAXONE 2, GILENYA 2, REBIF 2, TECFIDERA 2 FEMRING FETZIMA fluorouracil cream 0.5% FORTAMET FOSAMAX PLUS D FOSRENOL FREESTYLE STRIPS ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA metformin, metformin ext-rel alendronate, ibandronate, risedronate, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO FROVA 5 naratriptan 5, rizatriptan 5, sumatriptan nasal spray 5, sumatriptan tablet 5, zolmitriptan 5, RELPAX 5, ZOMIG NASAL SPRAY 5 GENOTROPIN 2 HUMATROPE 2, NORDITROPIN 2 GLUMETZA HUMALOG metformin, metformin ext-rel NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN INCRUSE ELLIPTA INNOPRAN XL NOVOLIN atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO 5 eszopiclone 5, zolpidem 5, zolpidem ext-rel 5, SILENOR 5 INTUNIV INVOKAMET INVOKANA ISTALOL JALYN KAZANO KOMBIGLYZE XR LASTACAFT amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE XIGDUO XR FARXIGA, JARDIANCE timolol maleate solution, BETIMOL finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO JANUMET, JANUMET XR, JENTADUETO JANUMET, JANUMET XR, JENTADUETO azelastine, cromolyn sodium, PATADAY, PATANOL, PAZEO DRUG NAME(S) LESCOL XL LIPITOR LIPTRUZET LIVALO LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN LUNESTA 5 eszopiclone 5, zolpidem 5, zolpidem ext-rel 5, SILENOR 5 Matzim LA MENEST MENOSTAR MICARDIS, MICARDIS HCT diltiazem ext-rel (except generic Cardizem LA) estradiol, estropipate, PREMARIN estradiol MONOVISC 2 GEL-ONE 2, HYALGAN 2, SUPARTZ FX 2 NAPRELAN NESINA NITROMIST NORITATE NORVASC celecoxib, diclofenac sodium, meloxicam, naproxen JANUVIA, TRADJENTA nitroglycerin lingual spray, NITROLINGUAL, NITROSTAT metronidazole, sulfacetamide-sulfur, FINACEA, SOOLANTRA amlodipine NUTROPIN AQ 2 HUMATROPE 2, NORDITROPIN 2 OLEPTRO OLUX-E OMNARIS trazodone clobetasol foam OMNITROPE 2 HUMATROPE 2, NORDITROPIN 2 ONGLYZA JANUVIA, TRADJENTA ORTHOVISC 2 GEL-ONE 2, HYALGAN 2, SUPARTZ FX 2 OSENI OXYTROL PANCREAZE PENNSAID PERTZYE PEXEVA PLAVIX JANUMET, JANUMET XR, JENTADUETO oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, CREON, ULTRESA, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL CREON, ULTRESA, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, BRINTELLIX, FLUOXETINE 60 MG, VIIBRYD clopidogrel, BRILINTA, EFFIENT PLEGRIDY 2 AUBAGIO 2, BETASERON 2, COPAXONE 2, GILENYA 2, REBIF 2, TECFIDERA 2 PRALUENT 2 REPATHA 2 PRECISION XTRA STRIPS PRED MILD PREFERAOB, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL

DRUG NAME(S) PREFEST PRENATAL PLUS PREVACID PROTONIX PROTOPIC QNASL RAYOS RELION INSULIN RELISTOR RHINOCORT AQUA RIOMET estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL lansoprazole, pantoprazole lansoprazole, pantoprazole tacrolimus, ELIDEL, methylprednisolone, prednisone NOVOLIN INSULIN MOVANTIK metformin, metformin ext-rel ROZEREM 5 eszopiclone 5, zolpidem 5, zolpidem ext-rel 5, SILENOR 5 SAIZEN 2 HUMATROPE 2, NORDITROPIN 2 SKELID SURE-TEST STRIPS SYMBICORT alendronate, risedronate ADVAIR, DULERA SYNVISC 2, SYNVISC-ONE 2 GEL-ONE 2, HYALGAN 2, SUPARTZ FX 2 TANZEUM TEVETEN, TEVETEN HCT TRULICITY, VICTOZA DRUG NAME(S) TOVIAZ TRICOR TRIGLIDE TRILIPIX TRUETEST STRIPS TRUETRACK STRIPS TUDORZA VALCYTE VALTREX VANOS VASCEPA VERAMYST oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, fenofibrate, fenofibric acid fenofibrate, fenofibric acid fenofibrate, fenofibric acid valganciclovir acyclovir, valacyclovir VIEKIRA PAK 2 HARVONI 2 VIMOVO VITAFOL-ONE XOPENEX HFA ZETONNA ZUBSOLV ZYFLO, ZYFLO CR clobetasol cream, clobetasol lotion omega-3 acid ethyl esters celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole or pantoprazole generic prenatal vitamins, CITRANATAL PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA buprenorphine-naloxone sublingual tablet, SUBOXONE FILM montelukast, zafirlukast FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace may not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brandname drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.vivahealth.com to check coverage and copay information for a specific medicine. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 These medications may require prior authorization. Before going to the pharmacy, please have your doctor call toll-free: 1-866-814-5506. These medications may also require a higher percentage copay. 3 These medications may require prior authorization from VIVA Health. Before going to the pharmacy, please have your doctor call VIVA Health Medical Management toll-free at 1-800-294-7780, ext. 475. 4 Listing does not include generic Cardizem LA. 5 These medications may have quantity limitations. 6 Only covered under pharmacy benefit when excluded from your medical benefit. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. 2016. All rights reserved. 106-11947-1-040116 www.vivahealth.com